UCSF Study Challenges ER Overcrowding Theory

4.13.08

SAN FRANCISCO — Contrary to popular perception, the uninsured aren’t to blame for emergency room overcrowding, according to a new study from the University of California, San Francisco.

“There’s an extremely wide misunderstanding that it’s the uninsured” flocking to emergency departments, said Dr. Linda Lawrence, a Fairfax physician and president of the American College of Emergency Physicians.

“But (this study) reflects what the American College of Emergency Physicians has known for a long time,” Lawrence continued. “It’s not the uninsured who are clogging our ERs, and it’s also not patients who are there for nonurgent care.”

Erroneously blaming the uninsured as the source of ER overcrowding means politicians, policy experts, hospital administrators and health care advocates may miss addressing the real causes of the crisis of insufficient emergency medical care in many U.S. communities.

The nation’s strained ER system not only endangers individuals seeking emergency care, according to numerous analyses, but is ill-prepared to handle surges in demand following disasters such as earthquakes, terrorist attacks or disease outbreaks.

Between 1995 and 2005, the number of annual visits to ERs rose from 97 million to 115 million a 20percent increase according to the Centers for Disease Control and Prevention. Yet between those years, the number of U.S. hospitals offering emergency care declined by 9 percent.

And that surge in ER visits didn’t come from an influx of patients lacking health coverage, according to the study, published this week in the online edition of the Annals of Emergency Medicine.

In fact, during roughly the same time frame between 1996 and 2004 the number of visits to ERs by the uninsured actually declined by 1 percent, from 15.5 percent to 14.5 percent, the study reported. And the number of patients inappropriately visiting emergency departments for nonurgent needs another group often blamed for ER overcrowding also held steady at about 15 percent in those years, according to CDC statistics cited in the report.

Instead, the greatest increase in ER visits came from those with good incomes, health insurance and access to doctors.

Between 1996 and 2004, the number of insured patients visiting an ER who also had a regular doctor increased from 22percent to 29 percent. During that time, the proportion of ER patients from households earning at least four times the federal poverty level in excess of $50,000 a year grew from 52 percent to 59 percent.

Researchers used data from a survey of nearly 50,000 U.S. adults in 1996 and close to 40,000 in 2004. While the homeless weren’t included in these surveys, the CDC estimates that 0.4 percent of ER visits in 2005 were made by homeless individuals.

“People who have doctors and who are relatively well-off are still coming to emergency departments,” said Dr. Ellen Webber, lead author of the study and a UCSF emergency department physician.

The study noted the pervasive belief that uninsured individuals crowd ERs may stem from efforts to raise awareness of the costs borne by medical workers and hospitals caring for those who can’t pay.

Under federal law, ERs must treat all who seek care. The federal government, however, didn’t fund this mandated medical care, an arrangement most health professionals point to as unfair and contributing to the crisis by dissuading some hospitals from operating ERs or funding them sufficiently to meet demand.

The primary cause of emergency department overcrowding, the new study noted, is a lack of capacity to admit ER patients into the hospital. These patients can be “boarded” for hours and even days in emergency departments, occupying a bed while ill or injured patients idle in waiting rooms.

“That’s the biggest reason for the crowding, for the people in the hallways,” Webber said, referring to the now-common practice of treating ER patients in hallways on gurneys.

Lawrence said a new bill that was introduced in 2007 in both houses of Congress would, if passed, require the Centers for Medicare and Medicaid Services to gather data on the practice of boarding in ERs. Among other provisions, the Access to Emergency Medical Services Act seeks added revenue for emergency department physicians, who on average provide $140,000 in uncompensated care annually, according to the bill’s authors.

With this study confirming previous research on actual patient demographics in ERs, the solution for improving the nation’s strained ER system doesn’t lie simply in insuring more residents, Webber emphasized.

Even the insured are now seeking medical care in ERs, because their regular doctors can’t quickly fit them into their schedules when urgent issues arise, she said.

“They are going, because they have a new acute problem, and they can’t get seen in a manner that feels timely,” Webber said.

She pointed to the strains facing the Massachusetts health care system. In 2007, a landmark law took effect there, requiring residents to have medical insurance. But reports abound of long waits to see a physician, or even finding a doctor willing to take new patients. Leaders in that state are now pointing out that health care reform falls short without enough doctors, particularly primary care physicians.

“I have total sympathy for primary care doctors,” Webber added. “They are poorly reimbursed, working long, hard hours, and there really is no incentive.”

She said inducing more physicians to open primary care practices requires improved reimbursement policies, among other changes.

In addition, emergency departments are evolving, and now provide among the best options for rapid diagnosis and ready access to an array of specialists. Sometimes physicians refer patients with new symptoms to ERs, Webber added, knowing they’ll get the fastest diagnosis. ERs often offer CT scans,

“We don’t want everyone doing this,” she added. “But for a lot of people, it’s a good way to get an answer quickly.”

But with overcrowded ERs, patients are “competing” for this state-of-the-art care, and their health is put at risk by long waits.

ERs, Webber emphasized, have become integral to hospital services, and usage of them by the insured is only expected to increase.

“The point is we need to invest more in our emergency care,” she said. “People have spoken with their feet, and there’s no turning around this wave.”

But if misperceptions persist that ERs are money-losing operations mandated with providing uncompensated care, rather than potential sources of new revenue, they’ll continue to decline, Webber predicted.

“There’s been this myth for a long time,” she said. “And it’s resulted in hospitals not wanting to expand emergency departments.”

To view a free copy of the study, “Are the Uninsured Responsible for the Rise in Emergency Department Visits in the United States?”, visit the Annals of Emergency Medicine’s Web site at A href=”http://www.annemergmed.com/”>http://www.annemergmed.com .

HOW THE CHRONICLE ANALYZED THE 911 DATATo track emergency response times in San Francisco, The Chronicle obtained a copy of the city’s 911 dispatch logs for more than four years under the city’s Sunshine Ordinance and the California Public Records Act. The data included details of more than 300,000 medical calls from November 2003 through December 2007.

To calculate response times, the newspaper totaled the time that elapsed from the moment a dispatcher answered the phone to when the first ambulance or other unit reported arriving at the scene.

The paper then compared the results to the city’s goals for handling high-priority medical calls. San Francisco expects dispatchers to enter information about the call and dispatch an emergency vehicle within 2 minutes at least 90 percent of the time. The city also expects paramedics to arrive within another 4 1/2 minutes 90 percent of the time – for an overall response time of 6 1/2 minutes.

To calculate ambulance delays, the paper examined only those medical calls that were labeled as high-priority Code 3 or Echo, and focused on 189,942 high-priority medical calls since Feb. 1, 2004, when the city’s latest standards were implemented.

About 11 percent of these Code 3 or Echo calls were disregarded – those in which the time data appeared to be incomplete, because no arrival time was listed, or invalid, because the response time was zero or a negative number – indicating that help probably was already on the scene when the call came in, a medic failed to signal an on-scene time, or the computer-aided dispatch system was briefly down, skewing the time stamps.

The Chronicle sorted the dispatch data in other ways, such as comparing response times in different neighborhoods and for different years. The data also showed the disposition of many calls – what happened when medics arrived. Some patients refused assistance, others were rushed to the hospital, and others were declared dead.

There were limitations with the data. For example, the data does not show how long callers waited before dispatchers answered the phone. The city provided summary reports showing generally how long it takes the city to field calls, but did not provide raw data.

The disposition in cases was often missing. On-scene times were sometimes incorrectly recorded. Some calls were originally dispatched low priority, but were elevated to Code 3 lights and sirens once the patient’s condition became clear – or visa versa. There were discrepancies between the time stamps on 911 audio recordings and those in dispatch logs.

The Chronicle identified 439 cases since February 2004 in which the overall response time on a Code 3 or Echo priority call exceeded 6 1/2 minutes and the patient died. That number does not include cases that were labeled “obvious death” because of the caller’s description of the body when the 911 call was received. The city did not track the survival rate of more than 1,600 additional patients who received delayed ambulance responses – but were rushed with lights and sirens to the hospital.

Because the city redacted the names of callers, it was sometimes impossible to know how many times residents called the city before help arrived. The redactions also made it more difficult to identify victims of 911 delays. To find the families of victims, The Chronicle relied on other public records and interviews.

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